Setup: a right handed 32M presents with headaches and staring spells with automatisms of the mouth that have been noted by family. The patient feels 'blank' during these episodes. Prior to these episodes, he experiences funny taste sensations. CT showed a 4.6 x 3.2 cm hypodense lesion of the left temporal lobe without calcification. The lesion was T1 hypointense and FLAIR hyperintense with possible cystic necrosis. It had heterogenous enhancement, speckled SWI hypo intensity, and did not restrict.
In presenting this patient, I suggested that he be started on an AED and that we discuss biopsy vs. resection for tumor of likely glial tumor.
Sweatfest:
Attending: so would you biopsy or resect the tumor?
Me: Me?
Attending: Yes, you. You presented the patient.
Me: [stares helplessly at the resident who is busily turning pages in their list/avoiding eye contact]. Resect...
Attending: What structures would you be worried about in resection?
Me: Oh! Subcortical tracts subserving language.
Attending: What? oh... yes. That. What else?
Me: ...
Attending: did you look at the coronal views?
Me: Yes!
Attending: So what other structures would you be worried about in resection?
Me: [dying inside]
Attending: What are those enhancing structures passing through the tumor into the basal ganglia?
Me: [feeling redemption on the horizon] Thalamostriate arteries that are branches of th-
Attending: So you think you can get 90% of this tumor out without destroying the blood supply to the deep cortical structures?
Me: uhhhh....
Attending: probably not. We'll probably biopsy this one.
Pearls:
Examine temporal lobe lesions in coronal views to determine their involvement of deep cortical structures and their vascular supply.
Regarding the "90% resection" comment, I believe the attending was referencing this paper by Orringer et al. which showed that patients with glioblastoma that had greater than 90% resection had greater 1 year survival than those that did not.
Check out typical temporal lobe seizure semiology here.
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